Session I, Slide 1
Progestin-Only Injectable Contraceptives
Session I: Characteristics of Progestin-Only Injectables
Session I, Slide 2
ObjectivesAt the end of this session, participants will be able to:
1. Describe the characteristics of progestin-only injectables in a manner clients can understand:
a. What progestin-only injectables are and how they work (mechanism and onset of action)
b. Effectiveness
c. Side effects
d. Non-contraceptive health benefits
e. Possible health risks (complications)
f. Other characteristics (STI/HIV protection, ease of use, return to fertility, when to initiate and discontinue)
Session I, Slide 3
Objectives2. Demonstrate the ability to:
a. Screen clients for medical eligibility for injectables
b. Explain to clients the insertion, removal, and follow-up procedures
c. Explain when to return to the clinic
d. Address common concerns, misconceptions, and myths
e. Conduct follow-up for injectable clients in a way that enhances continuing safety, satisfaction, and acceptance
3. Describe when to start use of injectables.
4. Explain how to manage side effects.
5. Identify conditions that require switching to another method.
6. Identify clients in need of referral for injectable-related complications.
7. Demonstrate the preparation of supplies, equipment, and the client and the technique of administration (using a fruit or vegetable).
Session I, Slide # 4
An injection every 2 or 3 months, depending on type
• A contraceptive method given by deep intramuscular injection.
• Contains progestin (similar to the natural hormone progesterone), that is slowly released into blood from injection site.
• DMPA and NET-EN are the scientific names.
• Works mainly by stopping ovulation.
• No supplies needed at home.
Very effective and safe
• Very effective, provided client returns for injection at right time.
• Do not cause any serious health problems, cancer, or infertility, nor do they produce any significant change in blood pressure.
• For breastfeeding women, they do not affect the quality of the breast milk.
Key Points for Providers and Clients
Session I, Slide # 5
Often takes longer to get pregnant after stopping
• After stopping progestin-only injectables, there is a delay of several months before most women can get pregnant, and for some women it may be even longer.
• They do not make women permanently infertile.
Changes in monthly bleeding
• The most commonly reported side effects of progestin-only injectables are menstrual changes.
• In the first three to six months, women using progestin-only injectables commonly experience irregular bleeding or spotting and prolonged bleeding. After one year, women commonly experience infrequent bleeding, irregular bleeding and amenorrhea.
No protection against STIs or HIV/AIDS
• Provide no protection from STIs/HIV.
• For STI/HIV/AIDS protection, also use condoms.
Key Points for Providers and Clients
Session I, Slide 6
Types of Progestin-Only Injectables
• DMPA (depot medroxyprogesterone acetate)– Injection every 3 months (13 weeks)
• NET-EN (norethisterone enanthate)– Injection every 2 months (8 weeks)
• Have similar effectiveness, safety, characteristics and eligibility criteria
Source: CCP and WHO, 2010; Kingsley, 2010.
Session I, Slide 7
Effectiveness of Injectables
In this progression of effectiveness, where would you place progestin-only injectables?
Implants
Male Sterilization
Female Sterilization
Intrauterine Devices
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
Less effective
More effective
Injectables
Session I, Slide 8
Relative Effectiveness of Family Planning Methods
Method # of unintended pregnancies among1,000 women in 1st year of typical use
No method 850
Withdrawal 220
Female condom 210
Male condom 180
Pill 90
Injectable 60
IUD (CU-T 380A / LNG-IUS) 8 / 2
Female sterilization 5
Vasectomy 1.5
Implant 0.5Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) 397- 404, Elsevier Inc.
Session I, Slide 9
Progestin-Only Injectables:
Mechanism of Action
Source: Kingsley F and Salem R, 2010.
Thicken cervical mucus to block sperm
Suppress hormonesresponsible forovulation
Note: Do not disrupt existing pregnancy
Session I, Slide 10
Characteristics of Progestin-Only Injectables
• Safe and very effective
• Easy to use; requires no daily routine
• Long-lasting and reversible
• Can be discontinuedwithout provider’s help
• Can be provided outside of clinics
• Can be used by breastfeeding women
• Use can be private
• Does not interfere with sex
• Can be used by breastfeeding women
• Provide non-contraceptive health benefits
• Have side effects
• Cause delay in return to fertility
• Effectiveness depends on user getting injections regularly
• Provide no protection from STIs/HIV
Source: CCP and WHO, 2011
Session I, Slide 11
Progestin-Only Injectables:
Health Benefits
• Help protect against:– Risks of pregnancy– Endometrial cancer– Uterine fibroids
• May help protect against symptomatic pelvic inflammatory disease (PID) and iron-deficiency anemia
• Reduce sickle cell crises in women with sickle cell anemia
• Reduce symptoms of endometriosis (pelvic pain, irregular bleeding)
Source: CCP and WHO, 2011; Manchikanti, 2007.
Session I, Slide 12
Injectables and Risk of Breast Cancer
• No effect on overall risk of breast cancer
• Older studies found a somewhat increased risk during first 5 years of use
– May be due to detection bias or accelerated growth of pre-existing tumors
• Recent large study found no increased risk in current or past DMPA users regardless of age and duration of use
• Little research has been done on NET-EN
Source: Strom et al, 2004
Session I, Slide 13
Effect of DMPA on Bone Density
• DMPA users have lower bone density than non-users
• Women initiating DMPA use as adults regain most lost bone
• Long-term effect in adolescents unknown – Concerns about reaching peak bone mass
– Long-term studies are needed
– Generally acceptable to use
Source: Cromer, 1996; Cundy, 1994; WHO, 2010.
Session I, Slide 14
Infant Exposure to DMPA/NET-ENDuring Breastfeeding
DMPA and NET-EN have no effect on:
•Onset or duration of lactation
•Quantity or quality of breast milk
•Health and development of infant
Source: Koetsawang, 1987; WHO Task Force for Epidemiological Research on Reproductive Health, 1994a and 1994b; Kapp 2010; WHO, 2008; WHO, 2010; WHO, 2004, updated 2008.
Initiation before 6 weeks postpartum is generally not recommended. (WHO/MEC)
Session I, Slide 15
Injectables: Return to Fertility
• Return to fertility depends on how fast a woman fully metabolizes the injectable
• On average, women become pregnant 9–10 months after their last injection of DMPA
• Length of time injectable was used makes no difference
Sources: Pardthaisong, 1984; Schwallie, 1974.
Session I, Slide 16
Progestin-Only Injectables:
Side Effects
Headaches and dizziness
Many women experience no side effects. Possible side effects include:
Amenorrhea (no menses)
Weight gain Changes in mood
and sex drive
Abdominal bloating and discomfort
Prolonged or heavy bleeding irregular bleeding or spotting
Session I, Slide 17
Group Activity
Injectables Fact Sheet
Review the fact sheet.
What additional questions or comments do you have about the characteristics of progestin-only injectables?